Transformation to the Patient-Centered Medical Home in CareOregon Clinics

Principal Investigator: Richard T. Meenan, PhD, MPH, MBA
Institution: Center for Health Research–Kaiser Permanente
AHRQ Grant Number: R18 HS019146

Number and Type of Practices

This project included Medicaid patients at 17 safety net primary care clinics from six organizations.

Clinics varied in size, from 630 to more than 8,000 Medicaid patients among patients served.


Portland, Oregon

Transformational Elements

  • Accessible Services
  • Comprehensive Care
  • Coordinated Care
  • Patient-Centered Care
  • Quality & Safety

Overview of Transformation Efforts

CareOregon, a large nonprofit Medicaid managed care plan, began the Primary Care Renewal (PCR) initiative in 2006 to help selected safety net primary care clinics in the metropolitan Portland area implement the patient-centered medical home. The initiative included team-based and customer-driven care, barrier-free access through same-day and telephone appointments, proactive panel health improvement, and onsite or otherwise integrated behavioral health. Participating organizations received modest reimbursement and other support in return for implementing PCR. Fee-for-service payments were supplemented with risk-adjusted, capitated payments to cover the time of other team members and for population management services.

CareOregon organized an ongoing learning collaborative where multidisciplinary teams from each participating clinic shared ideas and best practices about primary care transformation. Learning sessions were initially held every 6 weeks, and then less frequently as PCR was implemented. A steering committee that included leadership from each organization (e.g., medical directors and chief operating officers) met monthly to set goals for, guide, and coordinate implementation activities. Quality improvement (QI) coaches from each clinic met regularly to go over Plan-Do-Study-Act QI cycles, review clinical and process performance measures, and develop effective implementation processes for transforming care at their clinics. A data and reporting workgroup met regularly with a consultant and senior data analyst from CareOregon to identify and share best practices.

Each organization developed its own workflows and identified a pilot team to implement team-based care first. After 8 months, the pilot teams began to spread the team-based care model to other teams in their practice, and over time, to other clinics in their organization. CareOregon also helped train two process improvement coaches for each clinic, including a member of the clinical team and a member of the management team.

Results of Transformation Efforts

All PCR clinics achieved the highest level of certification in Oregon’s Patient-Centered Primary Care Home Program. Qualitative interviews with organizational leaders revealed that implementation occurred in two distinct phases, starting with inspiration and continuing with implementation. Medical directors and executive leaders initially hoped that implementation would naturally follow from their vision for transformation, supported by the modest financial incentives. However, they soon realized that organizational system changes were required for sustained primary care transformation. Therefore, a more systematic approach was subsequently adopted for QI and changing workflow practices, data capture and measurement, and goal setting to support transformation.

Key Impacts of Transformation


  • By 2010, PCR clinics showed significant decreases in hospital admissions compared with non-PCR clinics. At 1 year post-implementation, 5.39 fewer inpatient admissions per month occurred in the PCR clinics than would have been expected without the program. At 2 years post-implementation, there were 10.72 fewer admissions per month, and after 3 years, 16.03 fewer admissions per month.
  • Both PCR and non-PCR clinics saw reduced levels of primary care utilization and costs per member per month over time. While the magnitude of these reductions was larger among PCR clinics, the difference between the PCR and non-PCR clinics was not significant.


  • Internal performance assessments suggest that PCR clinics successfully reduced wait times for appointments, improved diabetes outcomes, and decreased the number of ambulatory-sensitive hospitalizations.

Challenges to Transformation

Electronic health records were not uniformly in place across clinics during implementation of practice transformation, and existing electronic health record systems were often not capable of data extraction. Clinics assumed a significant resource burden to extract data for QI purposes given their limited budgets.

In order for transformative changes to be sustained, they must become a part of the systems and routines of each clinic, including training regimens for new staff. However, safety net clinics do not have the resources required to accomplish this quickly. Staff turnover can be problematic for these clinics when the midlevel champions leave or systems are not in place to train new staff on primary care transformation activities.

Lessons Learned and Implications for Others

  • Leadership: CareOregon cultivated engaged leadership with relatively scarce resources by convening a group of organizational leaders and having them co-design their own transformation plans. Thus, transformation leaders became trusted partners for sharing lessons and overcoming implementation hurdles.
  • Spreading transformation: The use of practice coaches is expensive and therefore may not be scalable nationwide. However, an incremental approach that cultivated in-house leaders who then developed technical expertise for implementation was found to be effective, and is potentially a more scalable model for spread of the medical home model.
Communication: Clear and effective communication between organizational leadership and frontline staff is essential for transformation efforts to be successful. Leadership needs to communicate what is expected and how long it will take, and then be open to feedback from clinic staff about what works and what doesn't.

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Page last reviewed October 2015
Page originally created October 2015
Internet Citation: Transformation to the Patient-Centered Medical Home in CareOregon Clinics. Content last reviewed October 2015. Agency for Healthcare Research and Quality, Rockville, MD.